Methods and devices for treating pelvic conditions

ABSTRACT

A device and method that provides a minimally-invasive approach to performing treatments on soft tissue, such as that found in the bladder. The device is useful for manipulating tissue such that treatment tools can be inserted into the tissue at a controlled depth. In some implementations, the device and method described herein are suited to provide therapy to non-mucosal target tissue (or a target volume of tissue) to modulate bladder function. In an example, energy can be delivered to denervate selected portions of the bladder, such as afferent nerves.

RELATED APPLICATIONS

This application claims benefit of and priority to U.S. ProvisionalApplication Ser. No. 62/002,742 filed May 23, 2014, entitled Method AndDevice For Treating Pelvic Conditions, which is related to U.S. patentapplication Ser. No. 14/030,869 filed Sep. 18, 2013, (now U.S. Pat. No.9,095,351) entitled Apparatus And Methods To Modulate Pelvic NervousTissue; U.S. patent application Ser. No. 14/285,627 filed May 22, 2014,(published as U.S. Pub. No. 2014/0257268) entitled Apparatus And MethodsTo Modulate Pelvic Nervous Tissue; U.S. patent application Ser. No.14/030,905, (published as U.S. Pub. No. 2014/0148798) filed Sep. 18,2013 entitled Apparatus And Methods To Modulate Bladder Function; andU.S. Provisional Patent Application No. 61/935,753 filed Feb. 4, 2014,entitled Devices And Methods For Treating Conditions Caused By AffarentNerve Signals, all of which are hereby incorporated by reference hereinin their entireties.

BACKGROUND OF THE INVENTION

Urinary incontinence (UI) is the involuntary leakage of urine. There areseveral types of urinary incontinence, including urge urinaryincontinence (UUI) and stress urinary incontinence (SUI). Urge urinaryincontinence is the involuntary loss of urine while suddenly feeling theneed or urge to urinate. Stress urinary incontinence, typicallyaffecting females, is the involuntary loss of urine resulting fromincreased abdominal pressure, such as generated by physical activity,exercising, coughing, sneezing, laughing, lifting, etc. Mixedincontinence combines attributes of SUI and UUI.

Overactive bladder (OAB) is the strong, sudden urge to urinate, with orwithout urinary incontinence, usually with frequency and nocturia. Theurge associated with overactive bladder can be assessed using thesubjective experience of the patient, with or without any objectivelyverifiable metric, condition, behavior, or phenomena.

Historically, attempts have been made to translate the subjectivepatient experience of overactive bladder into a verifiable clinicaltest. Based upon work in spinal cord injury patients, it washypothesized that the sensation of urgency and the result of urineleakage was due to non-volitional urinary bladder detrusor musclecontractions. Consequently, there was a push to implement urodynamictesting to observe and quantify the presumed detrusor contractions.However, the results found a poor correlation (e.g., 60%) betweenobserved detrusor overactivity and the experience of urgency, and alsofound that asymptomatic individuals may exhibit detrusor contractionsduring urodynamic testing.

Given the limitations of urodynamic testing, the diagnosis and treatmentdecisions for overactive bladder transitioned to being assessed whollyby the patient's subjective experience. However, the detrusor muscle andits contractions are still considered to have a major role in overactivebladder.

Bladder control is a complex combination of voluntary and involuntaryneurologic control, which responds to a highly distributed set ofafferent (sensory) nerves associated with the bladder. Also, there isevidence of a myogenic origin for at least a portion of bladder wallcontractile activity. While there are some descriptive hallmarks ofidiopathic overactive bladder (e.g., thickened wall, characteristic“patchy” denervation, changes in smooth muscle and collagen morphology,increased electrical connectivity), there is no specific anatomic causeof OAB (e.g., a lesion, defect, injury, etc.), and also it is believedthat there is no commensurate remedy for the cause. Neurogenic injury(e.g., spinal cord injury) and bladder outlet obstruction (BOO) can bothlead to overactive bladder due to a chronic state of bladder inflationand a “high pressure” bladder. However, resolution of an outletobstruction fails to rectify overactive bladder symptoms in asignificant fraction (e.g., 25%) of these patients.

Overactive bladder affects at least 33 million patients in the UnitedStates alone, representing 16% of the adult United States population androughly $12 billion dollars in healthcare cost. Overactive bladder andurinary incontinence significantly affect the quality of life and theability of patients to maintain their lifestyle, including socializing,mobility, or independence. Further, urinary incontinence is one of themost common reasons for entering long-term care facilities, such asnursing homes, and is also a significant risk factor for injury due tofalls resulting from hurrying to the toilet in response to urge.

Referring to FIGS. 1-3, the anatomy of the female bladder is describedto provide context for discussion of previously-known treatmentmodalities, and is illustrative of why a significant unmet need forimproved treatment modalities remains. In particular, FIG. 1 depicts alateral sectional of the anatomical structures of a bladder (B) and aurethra (U), while FIG. 2 depicts an anterior sectional view of thebladder and urethra. FIGS. 1-2 further illustrate a trigone (T),ureteral ostium (O) (also referred to as a ureteral orifice), detrusormuscle (D), a neck (N), an interureteric crest (C), a fundus (F), and abody (BB).

FIG. 3 depicts a cross sectional view of a wall of the bladder,including an intravesical region (IR) (also referred to as the cavity),mucous membrane (also referred to as the mucosa), lamina propria (LP),muscularis propria (MP), adventitia (A), and perivesical fat (PF). Themucous membrane lines the intravesical region (IR) of the bladder andincludes a three-layered epithelium, collectively referred to astransitional cell epithelium (TCE) or urothelium, and basement membrane(BM). The three layers of the transitional cell epithelium include thebasal cell layer, the intermediate cell layer, and the surface celllayer. The basal cell layer can renew the transitional cell epitheliumby cell division. New cells can migrate from the basal layer to thesurface cell layer, and the surface cell layer can be covered byglycosaminoglycan (GAG) layer (GL). The function of GAG layer iscontroversial, possibly serving as an osmotic barrier or even anantibacterial coating for transitional cell epithelium. The basementmembrane is a single layer of cells that separates transitional cellepithelium from the lamina propria.

Lamina propria (also referred to as the submucosa or suburothelium) is asheet of extracellular material that may serve as a filtration barrieror supporting structure for the mucous membrane and includes areolarconnective tissue and contains blood vessels, nerves, and in someregions, glands. Muscularis propria (also referred to as the detrusormuscle or the muscle layer) may be interlaced with lamina propria andmay have three layers of smooth muscle, the inner longitudinal, middlecircular, and outer longitudinal muscle.

When the bladder is empty, the mucosa has numerous folds called rugae.The elasticity of rugae and transitional cell epithelium allow thebladder to expand as the bladder fills with fluid. The thickness of themucosa and muscularis propria can range between approximately 2 to 5 mmwhen the bladder is full and between approximately 8 to 15 mm when thebladder is empty.

The outer surface of muscularis propria may be lined by adventitia Aabout the posterior and anterior surface of the bladder or by the serosaabout the superior and upper lateral surfaces of the bladder.Perivesical fat (PF) can surround the bladder outside of the serosa oradventitia. In some cases, a variety of fascia layers may surround orsupport the organs of the pelvis. Collectively, the fascias near theurinary bladder can be referred to as perivesical fascia.

A number of therapies have been developed for treating overactivebladder, including delivery of anticholinergic drugs, bladderretraining, sacral nerve stimulation (SNS), intravesical drug infusions,surgical denervation procedures, surgeries to increase bladder volume(e.g., detrusor myomectomy, augmentation cystoplasty) and botulinumtoxin (e.g., Botox®, Dysport®, etc.) injections into the bladder wall.Each of these therapies has drawbacks, as described below.

Anticholinergic drugs, used alone or in combination with traditionalnonsurgical approaches, such as bladder retraining, Kegel exercises,biofeedback, etc., often is used as first-line therapy for overactivebladder; however, the mode of action is uncertain. Anticholinergic druguse was initially thought to decrease contractions of the detrusormuscle during the filling stage (e.g., detrusor muscle overactivity,unstable detrusor muscle, etc.). However, it is now believed thatanticholinergic drugs may not change detrusor muscle contractility, butinstead modulate afferent (e.g., cholinergic) nervous traffic to thecentral nervous system.

Efficacy of anticholinergic drugs is generally quite modest, asapproximately 50% of patients find such therapy subjectively inadequate.A reduction of 10% to 20% in the number of micturations per day (e.g.,from 11 micturations to 9 micturations) and a reduction of 50% inurinary incontinence episodes (e.g., from 2 per day to 1 per day) istypical. However, these effects are frequently inadequate tosignificantly improve patient quality of life (QOL). Many patients wouldnot even notice a change of 2 micturations per day unless they arekeeping a log for a formal study. The remaining urinary incontinenceepisodes, although slightly less in number, continue to maintain thestigma and lifestyle limitations of the disease, such as the inabilityto travel or to be active, social withdrawal, etc. In addition,anticholinergic drugs can have side effects, including dry mouth,constipation, altered mental status, blurred vision, etc., which may beintolerable, and in many instances outweigh the modest benefitsattained. Approximately 50% of patients abandon anticholinergic therapywithin 6 months.

Sacral nerve stimulation (SNS) has a higher level of efficacy (e.g., upto 80% in well-selected and screened patients), but here too the mode ofaction is not well understood. The clinical benefit of SNS for urinaryincontinence was a serendipitous finding during clinical trials of SNSfor other conditions. The SNS procedure has a number of drawbacks: it isexpensive and invasive, and requires surgery for temporary leadplacement to test for patient response, followed by permanent leadplacement and surgical implantation of a pulse generator in patients whoresponded favorably to the temporary lead. Regular follow-ups also arerequired to titrate SNS stimulation parameters, and battery replacementsare necessary at regular intervals.

A variety of surgical denervation or disruption procedures have beendescribed in the literature, but most have showed poor efficacy ordurability. The Ingelman-Sundberg procedure, first developed in the1950s and described in Ingelman-Sundberg, A., “Partial denervation ofthe bladder: a new operation for the treatment of urge incontinence andsimilar conditions in women,” Acta Obstet Gynecol Scand, 38:487, 1959,involves blunt surgical dissection of the nerves feeding the lateralaspects of the bladder near its base. The nerves are accessed from theanterior vaginal vault, with the dissection extending bilaterally to thelateral aspect of the bladder. The denervation process is accomplishedsomewhat blindly, using blunt dissection of the space and targeting theterminal pelvic nerve branches. Although capable of producing promisingresults, the procedure as originally proposed entails all of thedrawbacks and expense normally associated with surgical procedures.

McGuire modified the Ingelman-Sundberg procedure in the 1990s, asdescribed in Wan, J., et al., “Ingelman-Sundberg bladder denervation fordetrusor instability,” J. Urol., suppl., 145: 358A, abstract 581, 1991,to employ a more limited and central dissection within the serosal layerof the bladder, staying medial to the vaginal formices. Surgicalcandidates for the Modified Ingelman-Sundberg procedure can be screenedto isolate likely “responders” using sub-trigonal anesthetic injections.As reported in 1996 by Cespedes in Cespedes, R. D., et al., “ModifiedIngelman-Sundberg Bladder Denervation Procedure For Intractable UrgeIncontinence,” J. Urol., 156:1744-1747 (1996), 64% efficacy was observedat mean 15 month follow-up following the procedure. In 2002, Westneyreported in Westney, O. L., et al., “Long-Term Results OfIngelman-Sundberg Denervation Procedure For Urge Incontinence RefractoryTo Medical Therapy,” J. Urol., 168:1044-1047 (2002), achieving similarefficacy at mean 44 month follow-up after the procedure. More recently,in 2007, Juang reported in Juang, C., et al., “Efficacy Analysis ofTrans-obturator Tension-free Vaginal Tape (TVT-O) Plus ModifiedIngelman-Sundberg Procedure versus TVT-O Alone in the Treatment of MixedUrinary Incontinence: A Randomized Study,” E. Urol., 51:1671-1679(2007), using a combination of a transvaginal tape (TVT) sling (the“gold standard” surgical therapy for stress incontinence) and theModified Ingelman-Sundberg procedure for mixed incontinence patients andshowed a significant benefit for including the ModifiedIngelman-Sundberg procedure, over the TVT sling alone, out to 12 monthsfollow-up following the procedure.

Despite its clinical success, however, the Modified Ingelman-Sundbergprocedure has not been widely adopted, as it is highly invasive andrequires general anesthesia. Further, the terminal nerve branches arenot visible to a surgeon, and thus, the dissection must be performedusing approximate anatomical landmarks rather than using directvisualization of target nerve branches. Possible complications of theModified Ingelman-Sundberg procedure include the risks associated withanesthesia, blood loss, vaginal numbness or fibrosis, adhesions,fistulas, vaginal stenosis, wound infection, or dyspareunia (pain withintercourse). Perhaps most importantly, efficacy of the ModifiedIngelman-Sundberg procedure may be dependent upon surgical skill andtechnique.

More recently, another therapy involving injection of botulinum toxin(e.g., Botox®) into the bladder wall has been developed to address thesymptoms of overactive bladder by blocking nerve traffic and causingtemporary muscle paralysis following injection. During the injectionprocedure, which may be performed in a physician's office under localanesthesia, a cystoscope is introduced into the bladder through theurethra and a number of separate cannula injections (e.g., 20-30) aremade into the bladder wall. Initially the trigone, the area of thebladder defined by the ostia of the two ureters and the urethra, wasavoided due to concerns about procedural pain due to dense afferentinnervation of the trigone region and the potential for vesicoureteralreflux. However, the trigone region has more recently been included, andsometimes specifically targeted to the exclusion of the dome of thebladder. Initially, botulinum toxin was assumed to act only on theefferent motor nerves (e.g., causing partial paralysis of the detrusormuscle). More recent research indicates that botulinum toxin may have aneffect on afferent sensory nerves as well. U.S. Pat. No. 8,029,496 toVersi provides an example of a system for delivering such a therapeuticagent to the trigone of the bladder through the vaginal wall.

Typically, botulinum toxin injections achieve a fairly high level ofefficacy (e.g., resolution of symptoms), with maximum changes incystometric capacity peaking at 4 weeks and complete continence beingachieved in about half of patients. However, botulinum toxin does carrywith it the risks of systemic effects, such as flu-like symptoms,nausea, weakening of respiratory muscles, transient muscle weakness,allergic reaction, or developed sensitivity. Other adverse eventsassociated with botulinum toxin injections include acute urinaryretention (AUR), large postvoid residual volume (PVR), difficulty inurination (“straining”), and urinary tract infection (UTI). Challengeswith botulinum toxin therapy include procedural skill (e.g., dexteritywith cystoscope and needle), uncontrolled drug diffusion, variableneedle penetration depth, and reproducibility of technique. In addition,the effects of botulinum toxin wear off with time, typically after 6-9months, requiring repeat injections for the lifetime of the patient.

Stress urinary incontinence, typically affecting females, is an anatomicissue where the pelvic floor has been damaged and weakened, such asduring childbirth. Here, front line therapies are conservative (e.g.,Kegel exercises or biofeedback), and a variety of minimally invasivesurgical therapies are available as second line therapies. Examples ofthese second line therapies include sling procedures, bladder necksuspension, transvaginal tape (TVT), etc. In each, the procedure is aday surgery performed on an outpatient basis. Success rates are high,and the procedures have been embraced by the medical community.

In addition, new therapies have been developed to treat stress urinaryincontinence, such as the Renessa system offered by Novasys Medical,Inc., which is used in an office-based procedure. U.S. Pat. No.6,692,490 to Edwards, assigned to Novasys Medical, discloses thetreatment of urinary incontinence and other disorders by the applicationof energy and drugs.

Finally, a majority of males will develop some degree of urinaryobstruction from benign prostate hyperplasia (BPH), or “enlargedprostate”, over their lifetime. Since urinary obstruction is known to bea cause of overactive bladder, bladder symptoms in males are generallypresumed to be secondary to the enlarged prostate. However, resolutionof the urinary obstruction (e.g., by one of the many variants oftransurethral treatments of the prostate) does not resolve the bladdersymptoms in about a quarter of the patients. Thus, it would be desirableto offer a minimally invasive therapeutic procedure targeting theseremaining patients whose symptoms remain after prostate therapy.

Further, there is a growing preference for “watchful waiting” forprostate disease, even for cases of actual prostate cancer, and many ofthese patients will develop symptoms of overactive bladder due to theurinary obstruction from their growing prostate. Thus, there is thepotential to provide a therapy that targets the bladder symptoms priorto or instead of providing therapy targeting the prostate itself.

Males also may experience idiopathic OAB, that is OAB not secondary toan enlarged prostate or other urinary obstruction, and require a primarytherapy for the OAB symptoms.

In view of the foregoing, it would be desirable to provide a minimallyinvasive procedure for modulating bladder function to treat or resolveoveractive bladder and provides durable relief for patients sufferingfrom these debilitating conditions.

OBJECTS AND SUMMARY OF THE INVENTION

The invention is directed to apparatus and methods configured to performa variety of foreseen and unforeseen medical procedures and therapies.By way of non-limiting example, the apparatus and methods of theinvention are suited to provide therapy to non-mucosal target tissue (ora target volume of tissue) to modulate bladder function. In an example,energy can be delivered to denervate selected portions of the bladder,such as afferent nerves located within or proximate to the trigoneregion of the bladder wall, to modulate bladder function and therebyprovide relief for at least one of a sense of urge, incontinence,frequency, nocturia, bladder capacity, or pain.

In some examples, denervation may be accomplished by delivering thermalenergy (e.g., using RF energy, microwaves, or high intensity focusedultrasound) to layers of the bladder wall beneath the mucosal layer,such as within or proximate to the trigone region. In the context ofthis disclosure, tissue of the female anatomy targeted for energydelivery may include one or more tissue layers of the bladder wallbeneath the mucosa and extending to (but not including) the anteriorvaginal wall, and are collectively referred to herein as“non-superficial tissue.” Further, in the context of this disclosure,tissue of the male anatomy targeted for energy delivery may include oneor more layers of the bladder wall beneath the mucosa and extending toand including the perivesical fat layer, and in the context also isreferred to as “non-superficial tissue”. In still other examples,thermal energy may be delivered to neural tissue, such as a pelvic nerveor its branches, within or proximate to the bladder wall to modulatenerve traffic to or from at least a portion of the bladder, therebymodulating bladder function. In accordance with some examples, suctionmay be used to grasp and conform a mucosal surface of the bladder wallto a first surface of a device, and energy can be delivered tonon-superficial target tissue at a substantially uniform depth from themucosal surface. Cooling also may be provided to reduce heat buildup inthe mucosa. However, in some examples, a mucosal surface of the bladderwall superficial to the non-superficial target tissue can be retainedsubstantially intact without cooling, such as by inserting an energydelivery element in the non-superficial target tissue at a substantiallyuniform distance from the first surface of the device and deliveringenergy to the non-superficial target tissue from that substantiallyuniform depth beneath the mucosal surface. The systems and methodsdescribed herein may be configured to deliver energy, such as thermalenergy, to target tissue either from within a lumen or cavity of a bodyorgan, for example, the bladder, or from a lumen or cavity of anadjacent organ, such as the vagina.

In the alternative, or optionally in addition, the systems and methodsdescribed herein may provide that one or more areas of the bladder beisolated or supported such as to suppress the sense of urgency. Forexample, surgical barriers or treatments may be used to reduce stretchof a selected region of the bladder, such as the trigone, oralternatively used as an adjunct to energy delivery to prevent nerveregrowth in a treated portion of the bladder.

This overview is intended to provide an overview of subject matter ofthe present patent application. It is not intended to provide anexclusive or exhaustive explanation of the invention. The detaileddescription is included to provide further information about the presentpatent application.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other aspects, features and advantages of which embodiments ofthe invention are capable of will be apparent and elucidated from thefollowing description of embodiments of the present invention, referencebeing made to the accompanying drawings, in which

FIG. 1 is a lateral sectional depiction of the anatomy of a femalebladder and urethra;

FIG. 2 is an anterior sectional depiction of a female bladder andurethra;

FIG. 3 is a cross sectional depiction of bladder wall tissue;

FIG. 4 is a perspective view of an embodiment of a device of theinvention;

FIG. 4a is a perspective view of the device of FIG. 4 with the endoscopein a partially retracted position;

FIG. 5 is a detail perspective view of the portion of the device shownin area 5 of FIG. 4;

FIG. 5a is a detail perspective view of the portion of the device shownin area 5 a of FIG. 4 a;

FIG. 6 is a perspective view taken from a proximal end of an embodimentof a device of the invention;

FIG. 7 is a plan view of an embodiment of a device of the invention;

FIG. 8 is an elevation view of an embodiment of a device of theinvention;

FIG. 9 is a bottom view of an embodiment of a device of the invention;

FIG. 10 is an elevation of an embodiment of a suction head of theinvention;

FIG. 11 is a perspective view of an embodiment of a suction head of theinvention;

FIG. 12 is a plan view of an embodiment of a suction head of theinvention;

FIG. 13 is a plan view of an embodiment of a suction head of theinvention;

FIG. 14 is a perspective view of an embodiment of a suction head of theinvention with electrode sets in an extended position;

FIG. 15 is a cutaway view of an embodiment of a suction head of theinvention showing the detail of the inner suction chamber;

FIG. 16 is an axial cross sectional view of an embodiment of a suctionhead of the invention;

FIG. 17 is a depiction of a side view of an area of a female bladdertargeted during an example of a method of the invention;

FIG. 18 is an anterior sectional depiction of a bottom portion of afemale bladder;

FIG. 19 is a depiction of an embodiment of a device of the inventionbeing inserted into a female bladder;

FIG. 20 is a depiction of a step of an embodiment of a method of theinvention;

FIG. 21 is a depiction of a step of an embodiment of a method of theinvention;

FIGS. 22-33 depict various ablation patterns made practicing anembodiment of a method of the invention;

FIG. 34 is an elevation of a distal end of an embodiment of theinvention;

FIG. 35 is an elevation of a distal end of an embodiment of theinvention;

FIG. 36 is an elevation of a distal end of an embodiment of theinvention;

FIG. 37 is a perspective view of a distal end of an embodiment of theinvention;

FIG. 38 is an elevation of an embodiment of the invention;

FIG. 39 is an elevation of an embodiment of the invention;

FIG. 40 is a sectional view of the embodiment of FIG. 38 taken alongsection lines 40-40;

FIG. 41 is a sectional view of the embodiment of FIG. 38 taken alongsection lines 41-41;

FIG. 42 is a sectional view of the embodiment of FIG. 38 taken alongsection lines 42-42;

FIG. 43 is a perspective view of an embodiment of a device of theinvention;

FIG. 44 is a bottom view of an embodiment of a device of the invention;

FIG. 45 is a detail view of cutout 45 of FIG. 44;

FIG. 46a is a cross-sectional view of a distal portion of an embodimentof the invention;

FIG. 46b is a cross-sectional view of a distal portion of an embodimentof the invention employing a tilted suction head;

FIG. 47 is a side elevation of an embodiment of a device of theinvention;

FIG. 48 is a sectional view of the embodiment of FIG. 47 taken alongsection lines 48-48;

FIG. 49 is a sectional view of the embodiment of FIG. 47 taken alongsection lines 49-49;

FIG. 50 is a sectional view of the embodiment of FIG. 47 taken alongsection lines 50-50;

FIG. 51 is a side elevation of an embodiment of a device of theinvention;

FIG. 52 is a side elevation of an embodiment of a device of theinvention;

FIG. 53 is a perspective view of an embodiment of a distal end of adevice of the invention;

FIG. 54 is a side elevation of an embodiment of a distal end of a deviceof the invention;

FIG. 55 is a perspective view of an embodiment of a distal end of adevice of the invention;

FIG. 56 is an elevation view of a distal end of an embodiment of theinvention being used with a flexible embodiment of an endoscope; and,

FIG. 57 is an elevation view of a distal end of an embodiment of theinvention being used with an articulated embodiment of an endoscope.

DESCRIPTION OF EMBODIMENTS

Specific embodiments of the invention will now be described withreference to the accompanying drawings. This invention may, however, beembodied in many different forms and should not be construed as limitedto the embodiments set forth herein; rather, these embodiments areprovided so that this disclosure will be thorough and complete, and willfully convey the scope of the invention to those skilled in the art. Theterminology used in the detailed description of the embodimentsillustrated in the accompanying drawings is not intended to be limitingof the invention. In the drawings, like numbers refer to like elements.

FIG. 4 illustrates an embodiment of a system 10 for treatment of bodytissue, such as the bladder. Generally, the system includes a treatmentdevice 20 and may include an endoscope 12. The treatment device 20 has aproximal end 22, a distal end 24, and an elongate shaft portion 26between the proximal end 22 and the distal end 24.

The proximal end 22 of the treatment device 20 may include a handleassembly 30, detailed in FIG. 5. The handle assembly 30 may include abody 32, a sliding mechanism 34 (FIGS. 4a and 5a ), one or more suctionports 36, and at least one receiver 38 for an electrode set, describedbelow. The handle assembly 30 generally serves to secure the endoscopeposition relative to the treatment device and also to provide acomfortable grip for the user. To this end, the handle assembly 30 maytake on any number of ergonomic shapes. An alternative shape to thatshown in the Figures is a “pistol grip” shape.

The sliding mechanism 34 functions to receive and control thelongitudinal or axial placement of the endoscope 12 relative to thetreatment device. The sliding mechanism 34 includes a sliding tube 40(see FIG. 5a ) that is slidingly received by the body 32 of the handleassembly 30. The sliding tube 40 includes a stop 42 that rides within agroove 44 in the body 32. The stop 42 and groove 44 define the extentsof the longitudinal movement, and prevent rotation, of the slidingmechanism 34 relative to the body 32. It can be seen that the body 32accommodates an endoscope 12 inserted into a proximal end thereof. Aconventional Hopkins rod endoscope is shown, but alternative imagingdevices are contemplated as well, such as endoscopes having cameras ator near their tips. The sliding tube 40 can be seen in a fully insertedposition in FIGS. 4 and 5 and a partially retracted position in FIGS. 4aand 5a . A camera (not shown) may be connected to the eyepiece.

FIG. 6 shows a perspective view of the proximal end of the handleassembly 30 without the endoscope 12 inserted therein. It can be seenthat the sliding tube 40 defines a proximal end of a scope channel 16that receives the endoscope 12 and extends substantially the length ofthe treatment device 20. The sliding tube 40 also provides a cutout 46for accommodating a vertical control post and/or light input port 18 ofthe endoscope 12. The cutout 46 establishes a radial relationshipbetween the treatment device 20 and the endoscope 12 when the endoscopeis fully inserted into the sliding tube 40 of the sliding mechanism 34.The hemispherical design of the cutout allows a user to easily retractthe endoscope 12 slightly from the sliding tube 40 and rotate the scope12 if the user desires to alter the viewing angle of the scope withoutrotating the treatment device 20 within the patient.

The sliding mechanism 34 also includes a locking tab 48 that extendsthrough the sliding tube 40 and frictionally engages the endoscope 12when depressed. The locking tab 48, when engaged with the endoscope 12,prevents longitudinal movement of the endoscope 12 relative to thesliding tube 40.

While the sliding mechanism 34 is a manual slide mechanism, otherconfigurations are anticipated. Non-limiting examples of these otherconfigurations include dials, rack-and-pinion mechanisms, triggermechanisms, rocker switch configurations, worm drives, gears, steppermotors, and the like.

Below the scope channel 16, the body 32 of the handle assembly includesat least one suction port 36. The embodiment shown in the Figuresincludes two suction ports 36. These suction ports 36 are in fluidcommunication with a suction channel 17 that extends the length of thetreatment device 20. The suction ports 36 are shown with standardLuer-Lok fittings but this is shown by way of example only and is notintended to be limiting.

Additionally, these suction ports 36 may be used for irrigation orinfusion purposes. Flow control valves (not shown), such as stopcocksmay be used to connect suction and/or aspiration sources to the ports36. One or more of the ports 36 may also act as a vent to theatmosphere. It is also envisioned that one or more of the fittings maybe permanently or episodically connected to a syringe, which may be usedto instill or extract volumes of fluid into or out of the anatomicstructure in which the device is used.

The body 32 of the handle assembly 30 also may define one or morereceiver 38 for an electrode set. The embodiment shown in the figuresincludes a receiver 38 that accommodates two electrode sets 54, one oneither side of the scope channel 16 and the suction channel 17. Thereceiver 38 is sized and shaped to house the proximal ends of theelectrode sets 54 and provides cannula ports 50 that lead to cannulachannels 52. The cannula ports 50 are shown as being funneled in orderto facilitate easy cannula insertion.

The electrode sets 54 are best shown in FIGS. 4 and 7-9. The electrodesets 54 generally include an electrode 56 and a cannula 58 extendingdistally therefrom. Connecting wires connecting the electrodes 56 to apower source are to be understood but not shown. The electrode 56extends through and energizes the cannula at the tip. An all-in-oneelectrode set, in which the conductive end of the electrode is notcontained within a cannula is also contemplated. For purposes of clarityherein, the electrode 56 is considered that portion of the electrode setthat is connected to a power supply and provides the circuitry forenergizing the cannula. The cannula 58 is the energized portion of theelectrode set that transfers energy into the patient.

The electrode sets 54 and corresponding cannula channels 52 are sizedsuch that, when the electrode sets are fully inserted into the cannulachannels 52 so that the hubs of the cannulas 58 abut against thereceiver 38, the distal ends of the cannulas 58 extend a desired amountpast the distal ends 80 of the cannula channels. FIG. 14 shows thedistal end of the device with the cannulas 58 fully inserted. FIG. 14also shows insulation 59 surrounding all but the ends of the cannulas58, thereby limiting the effective treatment portion of the cannulas 58to the distal ends of the cannulas.

The electrode sets 54, once placed in the channels 52 and receiver 38,are movable between a retracted position and an inserted position. Theinserted position as described above, is achieved when the electrodesets 54 are fully inserted into the channels 52 so that the hubs of thecannulas 58 abut against the receiver 38. The retracted position isachieved when the electrodes 56 are pulled proximally as shown in FIG.4. In the retracted position, the distal ends of the cannulas 58 arecontained within the cannula channels 52 and do not extend out of thecannula channel ends 80. The receiver 38 is sized to accommodate theelectrodes 56 even when the electrode sets 54 are in the retractedposition.

It is to be understood that any suitable electrode may be utilized withtreatment device. While a preferred type is one that has a needle-shapedend or where an electrode resides within a cannula, such as thatmanufactured by Stryker, Cosman, Neurotherm, other electrodes are alsocontemplated, such as electrodes that are “one piece” and capable ofdirectly penetrating tissue without an external cannula. It is alsopreferable to use an electrode of the type that has a temperaturemeasurement element at its tip, such as an embedded thermocouple orthermistor. The types manufactured by Stryker, Cosman, Neurotherminclude this feature.

It is anticipated that embodiments of the system 10 may be providedwherein the electrodes and cannulas are integral to the treatment deviceitself rather than using separate components that are assembled by theoperator. Further, it is anticipated that the cannula advancement, shownhere as manual axial movement of each cannula separately, may bealternatively configured to include coupling of the cannulas forsimultaneous advancement and mechanisms to advance the cannulas.

The embodiment depicted in FIG. 4 does not include a mechanism foradvancing the cannulas 58 from the retracted to the advanced positions,as it is envisioned that this may be done manually. However, suchmechanisms are envisioned and could be provided for faster easieroperation of the device. Examples of such mechanisms include triggermechanisms or rotational helically threaded mechanisms to advance, andpossibly also retract the cannulas. Also anticipated are “spring loaded”mechanisms whereby stored energy, preferably in the form of a compactedspring, is released to drive the cannulas into the tissue.

It is envisioned that one or two electrode sets may be used to ablatetissue. If two electrode sets are utilized, as shown in the figures, abi-polar current may be applied, which concentrates current inrelatively planar space between the exposed portions of the cannulas.

Additionally, if two electrode sets are used in a bi-polar configuration(or more than two cannulas, but multiplexed such that they are energizedin pairs) wherein the cannulas are parallel to each other along theiruninsulated portion, the result is an energy deposition region which isuniform in cross section along the length of the uninsulated length.i.e., a treatment that is uniform in thickness and width along thelength of the cannula.

Referring to FIGS. 7-9, distal of the handle assembly 30 is the shaftportion 26. The shaft portion 26 is generally made up of the scopechannel 16, the suction channel 17 and the cannula channels 52. Thecannula channels 52 may be curved, as shown, to provide a smaller deviceprofile at the distal aspect. The shaft portion 26 is shaped and sizedfor insertion into a female urethra and may be relatively rigid,considering that the female urethra is relatively short and straight,compared to the male anatomy. An embodiment of the device designed foruse with the male anatomy is substantially similar to the embodimentsshown in the figures except that it may utilize a flexible shaft portionand may include a steering mechanism.

The treatment device 20 has a distal end 24, several embodiments ofwhich are detailed in FIGS. 10-15. The distal end 24 generally includesa suction head 60, distal cannula channel ends 80, an endoscope channeldistal end 90, and a tube holder 94.

The suction head 60 includes a flat face 62 and heel portion 63 with oneor more angled or curved faces 64. These faces 62 and 64 define at leastone suction aperture 66. The embodiments shown in the Figures include aplurality of suction apertures 66 in various shapes and arrangements,each of which is described in more detail below. The suction apertures66 lead to a suction chamber 68 that is in fluid communication with thesuction channel 17.

The suction head 60 may include a rounded, atraumatic distal end. Theflat face 62 may extend from the distal end of the suction head 60 tothe heel portion 63. The shape of the suction head 60 is designed toseal itself to soft tissue when a suction is applied to the suctionchamber 68. The flat face 62 establishes a seal with the soft tissuebeing targeted while the faces 64 of the heel portion 63 provide agentle transition to the cannula channel ends 80.

FIG. 16 shows an axial cross section of the suction head 60 taken at amid-point of the flat face 62. It is shown that the shape of the suctionhead 60 may be generally semi-circular. It may be formed from a portionof tube cut away, with a relatively flat face attached thereto.Apertures 66 may be cut or otherwise formed in the face to form openingsinto the interior suction chamber 68 of the suction head 60.

As stated above, the suction apertures 66 may be configured with varioussizes, shapes and arrangements. By way of example only, FIG. 11 shows anembodiment that uses four longitudinally-elongated apertures 66 in a 2×2arrangement in the flat face 62 and a single aperture 66 in the angledface 64. FIG. 12 shows an embodiment whereby the flat face 62 has 12circular apertures 66 in a 2×6 arrangement and a heel portion 63 has twoangled faces 64, one with two apertures 66 and one with a singleaperture 66. FIG. 13 shows an embodiment whereby the flat face 62 hassix transversely elongate apertures 66 and a heel portion 63 with afirst angled face 64 having a similar transversely elongate aperture 66and another angled face 64 with a single circular aperture 66.

Alternatively, or additionally, the apertures 66 may be square or anyother suitable shape, and combinations of various sizes and shapes arefurther contemplated both for the face and for the heel portion 63.Screen material (not shown) covering one or more of the windows is alsocontemplated. While the suction face shown in the figures is relativelyplanar, it is further contemplated that the face may have additionalfeatures, such as a raised rim at or near the edge, or along one or moreof the windows, or recessed features such as plugs that limit tissueincursion into the suction windows.

As stated above, the apertures 66 lead into the suction chamber 68,which is in fluid communication with the suction channel 17. The suctionchamber 68 is best shown in FIG. 15. In this embodiment, the suctionchamber 68 includes a baffle 72. The baffle 72 provides a barrierbetween the portion of the suction chamber 68 directly adjacent the flatface 62 of the suction head 60 and the portion of the suction chamberadjacent, or proximal of, the heel portion 63. When suction is appliedto tissue, a balance is sought between the strength of the vacuum beingapplied and the thickness and resiliency of the tissue. If the tissue istoo flexible for a given vacuum level, it may be that the tissue isdrawn into the suction chamber 68. The baffle 72 ensures that thesuction chamber 68 is not completely blocked by tissue. Thus, even iftissue is drawn into the heel portion 63, a path exists on the oppositeside of the baffle 72 for a vacuum to be established adjacent the flatface 62.

The heel portion 63 serves at least two functions. A first function ofthe heel portion 63 is to hold the tissue being engaged by the apertures66 in the angled faces 64 and prevent that tissue from being pushed awayfrom the suction head 60 when the electrode sets are being advanced intothe tissue. The orientation of the angled faces 64 assists in resistinglongitudinal movement by the tissue as a result of the advancement ofthe electrode sets.

As discussed above, a second function of the heel portion 63 is toprovide a transition between the flat face 62 and the cannula channelends 80. The vertical separation 74 (FIG. 10) between the flat face 62and the cannula channels 52 helps define the depth at which theelectrode sets/cannulas will penetrate and treat the targeted tissue.This vertical separation 74 allows the electrode sets to engage thetargeted tissue layer below the surface while avoiding or minimizingtreatment of the surface layer of the bladder interior.

More specifically, for bladder applications such as ablation of portionsof the trigone region of the bladder for treatment of overactivebladder, an example of a desired spacing is between 0.5 and 5.0 mm andpreferably between 1.0 and 4.0 mm. In this manner, it is believed thatthe thermal treatment of the submucosal tissue is concentrated at around0.0 to 7.0 mm depth from the bladder surface, which is where disruptionof the afferent nerves is believed to be effective, while minimizingthermal effects at the surface of the bladder. Greater or lesser spacingis also contemplated. The horizontal spacing 76 between the cannulas hasan impact on the width of the thermal treatment zone. A preferredspacing (shown in FIG. 14) is from 3 to 5 mm.

FIG. 10 illustrates a configuration where the axis of the cannula andthe suction head are parallel (i.e., the cannula is at a uniformdistance from the flat face 62 along the entire length of the face 62).While this is a preferred embodiment, it is also anticipated thatcertain non-zero angles between the paddle and cannula may offer certainbenefits. For example, a non-zero angle could be chosen to bias thedistal portion of the cannulas (and thus the therapy) to be at adifferent distance, either to bias the therapy to a different,preferential, depth, or to correct for differences in tissue propertiesor cannula tracking through the tissue.

FIGS. 10 and 15 show that the device distal end 24 also includes theendoscope channel end 90. The endoscope channel end 90 is angled suchthat, when the scope is retracted, the channel end presents anatraumatic profile.

FIG. 10 shows the end of the endoscope 12 in a partially advancedposition such that it protrudes out of the endoscope channel end 90. (Byway of comparison, FIG. 11 shows the scope 12 in a fully advancedposition). In this partially advanced position, the scope 12 has a viewof the suction head 60 as well as the tissue ahead of the suction head60.

It may be desirable for the endoscope to be spaced a distance radiallyfrom the surface of the suction head 60. Such spacing allows for theendoscope image to be less “blocked” by the presence of the suctionhead, facilitating more precise placement of the suction head againstthe desired body tissue. For bladder applications, and in the case wherethe endoscope has a 25-35 degree viewing angle, and is in the diameterrange of about 2.5 to 3 mm in diameter, and where the suction head is inthe range of about 4.5 to 5.5 mm in width, the spacing is preferablyabout 0.25 to 0.75 mm, although more or less is also contemplated.Greater spacing, while further minimizing the amount of blocked view ofthe suction head 60, also forces the overall device diameter to becomelarger, which is undesirable in applications where overall deviceprofile is desired to be smaller, such as the bladder, where the deviceis inserted into the urethra.

The device distal end 24 also may include a tube holder 94. The tubeholder 94 is a housing that may be used to connect the varioustubes/channels of the treatment device 20, as shown in FIG. 10. The tubeholder 94 secures the endoscope tube 16, the suction tube 17, and theelectrode tubes 52. This arrangement of the tubes, with a non-circularouter shape, allows the distal portion of the treatment device tocontain all the tubular elements in a desired arrangement, whileminimizing the overall periphery dimension, thus facilitating placementof the device into anatomy such as the urethra to access the bladder.

The aforementioned embodiments, and those additional embodimentdescribed below, may be useful to perform various procedures and methodsof the invention. For example, the embodiments may be used to treatbladder conditions such as Over-Active Bladder (OAB).

In this regard, FIG. 17 is a side view showing the female anatomy,including the bladder B, the uterus UT, the vagina V, and the urethra U.The trigone region T is shown in the dashed region. FIG. 18 shows anangled frontal-axial sectional view of the bottom portion of the bladderB, including the trigone region T, the ureteric ostia O, the bladderneck N, and the urethra U. While use of one of the device embodiments ofthe present invention is described in connection with the femaleanatomy, the same or similar device is contemplated for use in the maleanatomy as well. Some design alterations may be used, includinglengthening portions of the treatment device, and/or making the devicemore flexible and/or deflectable.

Treatment device 20 may be first inserted into the urethra and into thebladder, as shown in FIG. 19 (note that for purposes of simplicity, thecamera and light cable are not shown connected to the endoscope 12, norare the suction and infusion tubes or devices shown hooked up theports). The endoscope 12 is preferably positioned nearer the distal endof the suction head during this step. The treatment device 20 andendoscope 12 may be inserted directly into the urethra, or may be placedthrough a prior positioned tubular sheath (not shown).

If the target tissue is the trigonal region of the bladder, it may bedesirable to initially identify one of the ureteric ostia. The ostiummay be marked ahead of time by placement of a guide wire, a suture loop,or may be just visualized during the placement of the treatment device,with care to avoid placement of the treatment device at or too close theostium. In a preferred method, the tip of the suction head is placedjust medial to the uretic ostium. In another embodiment, the suctionhead is placed just inferior to the uretic ostium. In both cases, theureter itself is protected since as the ureter travels lateral andsuperior away from the visible ostia, placements medial and inferioravoid the obscured ureter.

The suction head 60 is placed onto the surface of the bladder tissue andthe suction is activated, causing the surface tissue of the bladder tocome into intimate contact with the face of the suction head, as shownin FIG. 20. Use of movement stabilization devices connected to thehandle are contemplated, for example, it may be beneficial to stabilizethe position of the treatment device after the suction is activated andthe tissue engaged with the suction head.

Though not shown, the tissue may actually protrude within the apertureson the suction head 60. The suction engages and holds secure the tissuerelative to the treatment device. Once the tissue is firmly secured tothe suction head 60, the endoscope 12 is preferably withdrawn to a pointwhere the scope tip is closer to the proximal end of the suction head60. This facilitates observation of the cannula advancement step. Theendoscope 12 may also be retracted just after the suction head tip 70 isplaced near the ostium, but before the suction is applied to the tissue.

The cannulas 58 are now advanced into the tissue, seen in FIG. 21, belowthe surface as prescribed by the offset distance of the cannula tubes 52to the face 62 of the suction head 60. The cannulas 58 of the electrodesets 54 may be activated by passage of electric current between them,which heats and ablates the tissue surrounding them and in between them,resulting in a heat affected zone 100. The heat-affected zone 100 ispreferably concentrated at a depth in the tissue. It is believed thatafferent nerves emanating from the bladder trigone may be ablated tolessen the sensory signals driving overactive bladder.

In one preferred embodiment, the chosen depth of the heat-affected zone100 is sufficient to protect the superficial layers of the bladder, suchas the mucosa, from damage. In another preferred embodiment, the chosendepth is chosen to target superficial layers such as the suburothelium.

Preferably the electric current is in the radio-frequency range, andpreferably it is delivered in a bi-polar fashion between the twoelectrodes. However, it is also contemplated that the two electrodescould form a mono-pole, and electric current could pass from them to agrounding pad, in a monopolar fashion. It is also contemplated, that asingle electrode be utilized as a monopolar current source.

Multipolar configurations are also contemplated, either as singlecannulas that are multipolar along their lengths or as multiple cannulas(3 or more) that are multiplexed or powered such that they operate inbi-polar modes, but possible in shifting patters. i.e., three cannulasthat form 2 bipolar pairs (middle cannula is the common).

Once the treatment of the target location is performed, the suction maybe released by venting the suction head 60 to atmosphere, the treatmentdevice 20 may then be positioned in a different target location, andanother ablation step may be performed, and repeated as many times asmay be necessary to treat the bladder.

A number of different ablation patterns may be considered for treatmentof the bladder. Such patterns are shown in FIGS. 22-31. Note that thepatterns are shown relative to the surface, but are intended to besubmucosal, as described above. The size of any one ablation zone may beaffected by the device size, and the cannula diameter and exposedlength, the spacing between the cannulas, the depth of the cannulas fromthe suction head face, and electrical parameters such as current,frequency, “on time”, and other variables.

One aspect of the desired pattern may be simply the size of eachablation zone. A single ablation zone may be adequate if the size islarge enough. However, a device that can yield a large ablation size maybe too large for simple passage through the urethra. A device smallenough to easily pass through the urethra may gain from multipleablation zones, such as shown in FIG. 22. Here, three relativelyparallel and evenly spaced zones 100 are created with three placementsteps. A first zone 100 a may be near one of the ostia O, a second zone100 b may be near the other ostium O, and a third zone 100 c may be nearthe middle of the trigone T.

More or fewer ablation zones 100 are also contemplated, for examplefive, as shown in FIG. 23. While many of the nerves associated with OABare believed to reside in the trigone, some may be lateral to theureteric ostia, and as such ablating regions of the bladder lateral toor posterior to the ostia may be of further benefit, as illustrated inFIG. 24.

In addition to relatively parallel spacing of the ablation zones 100(which may be performed by lateral manipulation of the treatment device,as the urethra and bladder are relatively soft pliable structures), itmay be easier for the physician to pivot or pan the treatment devicebetween ablation steps, resulting in a “fan shaped” pattern as shown inFIG. 25.

The nerves emanating from the trigone that are associated with OAB arefurther believed to coalesce near the ureteric ostia. FIG. 26 showsmultiple concentrated ablation zones 100 near the ostium O.

It is further contemplated that the distal portion of the treatmentdevice, with the suction head and distal portions of the electrode tubescould be laterally articulable, and allow for more angled ablation zones100, as illustrated in FIG. 27. Such an embodiment may be used with aflexible and articulable endoscope. Such angled or relatively horizontalablation zones may be combined with more vertical ablation zones and/orfan shaped zones as described above.

FIG. 28 shows a fan-shaped pattern of relatively narrow ablation zones100. The fan-shape results from pivoting the device between ablations,as opposed to translating the device. A high number of zones 100 iscreated (FIG. 28 shows five but more are possible). The zones 100preferably avoid going lateral of the ureteral ostia O.

FIG. 29 shows a pattern of ablation zones 100 that avoids theinter-ureteric bar—the horizontal ridge between the ureteral ostia O.The zones 100 are shortened sufficiently to accomplish this goal.

FIG. 30 shows a pattern of ablation zones 100 that encompasses both afan-shape as well as avoiding the inter-ureteric bar. Again, the zones100 are shortened sufficiently to avoid the inter-ureteric bar.

FIG. 31 shows a pattern of ablation zones 100 that is similar to thepattern shown in FIG. 26 but avoids the lateral burn to minimize thechance of causing trauma to the ureteral ostium O. This pattern mayinclude other zones. The zones 100 shown in this Figure merely highlightthose closest to the ostium O.

Making shorter ablation zones 100 may be accomplished using an electrodecannula having a shorter length of exposure L between the tip of thecannula 58 and the end of the insulation 59. FIGS. 32 and 33 showsimilar zone patterns except that the zones 100 in FIG. 32 are shorterthan the zones 100 shown in FIG. 33. The zones 100 in FIG. 32 were madeby a device shown in FIG. 34 having an exposure length L1 ofapproximately 10 mm. The zones 100 in FIG. 33 were made by a deviceshown in FIG. 35 having an exposure length L2 of approximately 15 mm.

As mentioned above, it may be desirable to create the ablation zone inthe submucosal tissue, so as to spare the surface tissue and urotheliumto minimize follow-up patient discomfort, risk of infection, and otherbenefits. In the treatment device embodiments described above, e.g. suchas the embodiment shown in FIG. 10, the offset of the electrode tubes 52from the face 62 of the suction head 60 influences the overallheight/profile of the treatment device. Depending on the desired tissuedepth for ablation, the height/profile of the treatment device could belarger than desired. An alternative embodiment that allows forrelatively deep tissue depth, but minimizes impact on device profile isillustrated in FIGS. 36 and 37.

The embodiment shown in FIGS. 36 and 37 utilizes electrode sets/cannula54 that may be pre-shaped to incorporate a curved design, for example,having an “S” shape near their distal ends or a general arcuate shape.When the electrodes 54 are advanced from the electrode tubes 52, theywill angle down from the tube axis, thus embedding in tissue below thetube axis. This allows for the electrode tubes 52 to have a smalleroffset distance from the face 62 of the suction head 60, which furtherallows for the treatment device 20 to have a smaller height/profile.Such cannula may be formed from an elastic material such as superelastic nickel titanium alloy, or other shapeable but elastic conductivematerials.

Another embodiment that facilitates a lower profile/height device in theportion that passes through the urethra is illustrated in FIGS. 38-42.In contrast with the embodiment of FIGS. 7-9, where the endoscopechannel or tube 16 extends alongside and parallel to the suction channelor tube 17, the alternative embodiment includes an endoscope tube 16that resides at an angle α to the suction tube 17, and to the side ofthe suction tube. The endoscope tube may be cut along a plane near thetop portion of the suction tube, so as to minimize the height of thetreatment device. This is best illustrated in the section views 40through 42.

At location 42, the suction tube 17 periphery is fully intact. Tofurther minimize overall profile from side-to-side, the endoscope tube16 may be “nested” into the suction tube 17 as shown, and the suctiontube 17 may be ovalized to narrow the width. Proceeding distally on thetreatment device, at section 43, the endoscope tube 16 resides higherwithin the suction tube 17, and the upper portion of the endoscope tube16 is exposed, which maintains the vertical height of the treatmentdevice in this area. Further distally, at section 44, the endoscope tube16 rests even higher within the suction tube 17, and more of theendoscope tube 16 is exposed. Further distally there is not endoscopetube 16, as the endoscope 12 would project distally without any tubingsurrounding it, as seen in FIG. 39, where the endoscope has been placedand extended above the distal aspect of suction head 60.

In use, this embodiment may be advanced “blindly” into the urethra untilthe suction head 60 is within the bladder, with the endoscope residingproximally, in the fully enclosed portion of the endoscope tube. Thisdistal portion 92 of the device (FIGS. 40-42) is lower in profile thanthe comparable portion of the embodiment of FIGS. 7-9, as there is noendoscope tube nor endoscope in this portion during this delivery step.

At this point, the endoscope 12 can be advanced into the bladder andabove the distal aspect of the suction head 60. Note also that theendoscope tip may be substantially spaced above the suction head 60,improving visualization, which may benefit the accurate placement of thesuction head tip 70 relative to the ureteric ostia O.

FIG. 43 illustrates a further embodiment of a treatment device 20 havinga lower profile/height in the portion that extends into the urethra.Similar to the embodiment of FIGS. 38-42, this embodiment positions theendoscope 12 at an angle relative to the elongate shaft portion 26 ofdevice 20.

Treatment device 20 includes an elongate suction tube 17 extending tothe distal portion 92 and suction head 60. In this embodiment, theendoscope tube 16, is at an angle α (FIG. 46) to the suction tube 17. Ahandle assembly 30 may be connected to the proximal ends of these tubesto hold them relative to each other. An optional sliding tube 40 may beincorporated into the handle assembly 30 for connection of the endoscope12 to the treatment device 20, similar to the sliding tube 40 describedin previous embodiments. A sliding mechanism, which may be similar tothe sliding mechanism 34 shown in FIGS. 4a and 5a and described above,may further be included to facilitate controlled advancement of theendoscope 12 relative to the treatment device 20. A connection hub 150secured to the treatment device 20 proximal of the distal portion 92preferably contains one or more receivers 38 to receive one or moreelectrode sets 54 (see, for example, FIG. 4a ). One or more suctionports 36 may also be connected to the handle assembly 30, and are influid communication with the interior of the suction tube 17, for eitherirrigation, suction, and/or venting of the interior of suction tube 17and suction head 60.

FIG. 44 is a bottom view of the treatment device 20, which shows theface 62 of the suction head 60. The suction head 60 is shown asincluding a plurality of apertures 66 leading to a suction chamber 68.These features are best seen in FIG. 45, which is a blow-up of area 45showing the distal portion 92 of treatment device 20.

FIG. 46a is a longitudinal section view of the distal portion 92 oftreatment device 20. Here it can be seen that the endoscope tube 16 hasa longitudinal axis 153 that extends at an angle α to the face 62. It isto be understood that the endoscope tube 16 may be curved, in which casethe angle α is measured to the longitudinal axis 153 at the opening 152.This may be described more accurately as measuring the angle between atangent of a curved longitudinal axis at the opening 152 and the face62.

The angle α is in the range of 1 to 20 degrees. The angle α may varydepending on the intended application. For example, when performingprocedures via a relatively long urethra, a shallower angle α may bedesired, for example in the range of 4 to 10 degrees. For femaleurethras of average length, good results have been achieved with anangle α of 6 to 8 degrees.

FIG. 46b shows an embodiment where the suction face is tilted forward.It is envisioned that such an embodiment may include a suction face 62that is tilted forward 5 to 10 degrees or more. If a tilted suction face62 is employed, angle α may increase, or an endoscope tube 16 may beused that is parallel with the suction tube 17.

The distal opening 152 of the endoscope tube is preferably flush withthe exterior surface of the suction tube 17 and tube holder 94, ifpresent, so as to maintain a relatively low profile and smooth exteriorsurface to ease passage of the treatment device 20 into the urethra andinto the bladder, when the endoscope 12 is in a retracted position.

FIG. 47 is a side view of the treatment device 20, with identifyinglocations of axial cross sectional views, 48-50.

FIG. 48 is a section view taken along section lines 48-48 of FIG. 47 andis just proximal of where the endoscope tube 16 intersects with thesuction tube 17, at 170. Also visible here are the cross-sectional facesof the electrode tubes 52, which extend distally towards the tip. Theendoscope tube 16 can be seen crossing the inside of the suction tube 17further distally.

FIG. 49 is a section view taken along section lines 49-49 of FIG. 47 andis just proximal of where the endoscope tube 16 emerges from the uppersurface of the suction tube 17. Further distally in this view, anaperture 66 is visible in the heel portion 63.

FIG. 50 is a section view taken along section lines 50-50 of FIG. 47 andis in the region of the device 20 where the endoscope tube 16 emerges tothe outside. Portions of the wall of the endoscope tube 16 are removed,so as to provide a smooth and low profile surface to the distal portion92. Also seen in this figure is an aperture 66, as well as the baffle 72if present. Note that in this embodiment, there may not be a separatetube holder 94 as in some of the above described embodiments, but thesuction tube 17 may be reshaped or have additional segments of differingshapes secured to it in the distal region. For example the shape may bemore “squared off”, as is shown, to facilitate incorporation andalignment of the electrode tubes 52, and to provide shape transition tothe suction head 60.

The portions of intersection 170 between the endoscope tube 16 andsuction tube 17 may be welded or similarly connected to secure the tubestogether and provide a hermetic seal therebetween.

FIG. 51 shows a system 10 with a treatment device 20 as described inconnection with the embodiments shown in FIGS. 43 through 47 above,together with an endoscope 12. In this figure, the endoscope is securedto the device 20, and in a retracted position. Note that the profile ofthe distal portion 92 of device 20 is low profile, suitable foradvancement through the urethra and into the bladder space. Once thedevice 20 is in the bladder, the endoscope 12 may be advanced (FIG. 52),in order to view the placement of the suction head 60 in one or moredesired locations, as described above in connection with the variousembodiments described previously.

FIGS. 53 through 55 show an embodiment similar to embodiments describedabove, such as, for example, the embodiment described in connection withFIG. 14. A positioning feature 160, shown in this embodiment as a hoop,is attached near the distal end of the suction head 60. Positioningfeature 160 may be attached to the face 62, and may be fabricated of anysuitable material that can be secured to the face 62. For example, thehoop 160 may be a metallic, such as stainless steel, and may be welded,brazed, soldered, or bonded to the face 62 with adhesive. Othermaterials are contemplated, including polymeric and elastomericmaterials. For example, the hoop may be made of a flexible material toensure that it is atraumatic. Though a hoop is shown, the positioningfeature 160 may take the form of one or more pointers, cross hairs, acircle, a wedge, or any other shape useful in providing a visual guide.

The positioning feature 160 may be used to aid in the placement of thedevice 20 relative to the desired anatomy to be treated. For example, toposition the suction head 60 in a desired position relative to a ureticostium in the bladder, the positioning feature 160 may be visualizedwith an endoscope 12 and visually lined up with the ostium. This canhelp assure that when the electrodes 54 are extended into the tissue,they will end up a desired distance from the ostium, such that when theyare activated, they don't adversely affect the tissue of the ureter orits ostium.

In one embodiment, when the ostium is viewed with the endoscope, and theostium is centered within the positioning feature 160, the hoop is sizedsuch that the extended electrodes 54 are close but not at the ostialtissue.

The positioning hoop 160 may optionally be added to any of the abovedescribed embodiments of the treatment device 20.

As mentioned above, in connection with the embodiments of FIG. 10, a 30degree downward looking angled endoscope may be preferable, as is anoffset spacing of the endoscope above the suction head, to aid inaccurate and relatively unobstructed positioning of the suction head.This is the case with a conventional Hopkins rod type of endoscope.

Alternatively, a flexible deflectable endoscope may be utilized, asshown in FIG. 56. The treatment device 20 may be any of the abovedescribed embodiments, such as that described in connection with FIG.10, but utilizing a flexible deflectable endoscope 110 as shown. Onceentry into the bladder has been made, the endoscope 110 is deflected toview in a downward direction, preferably a significant distance abovethe suction head, as shown. The viewing field 112 is indicated by thedashed line.

If a deflectable scope is used, the need for the offset of the endoscopetube as described in connection with FIG. 10 would not be as important,thus providing an opportunity to further lower the height of thetreatment device.

Alternatively, an articulating endoscope 120 such as indicted in FIG. 57may be utilized to enhance the visualization of the treatment device.One such articulating endoscope may have a side-facing camera 122 builtinto the deflecting tip portion. The height and angle of the imagerelative to the suction head may be altered by articulating the distaltip portion.

Although the invention has been described in terms of particularembodiments and applications, one of ordinary skill in the art, in lightof this teaching, can generate additional embodiments and modificationswithout departing from the spirit of or exceeding the scope of theclaimed invention. Accordingly, it is to be understood that the drawingsand descriptions herein are proffered by way of example to facilitatecomprehension of the invention and should not be construed to limit thescope thereof.

What is claimed is:
 1. An ablation instrument for insertion into a bodycavity, comprising: an elongate shaft including at least one cannulachannel and a scope channel; an electrode slidably associated with oneof the at least one cannula channels and being slidable between a firstposition and a second position, wherein in the first position, a distalend of the electrode is contained within the associated cannula channeland wherein in the second position, the distal end of the electrodeextends from a distal end of the associated cannula channel; a distalhead for engaging tissue; and a positioning feature associated with thedistal head, wherein said positioning feature facilitates a visualreference between the distal head and an anatomical feature as seenthrough a scope deployed through the scope channel, wherein saidpositioning feature comprises a hoop extending from a distal end of thedistal head, and wherein said hoop is sized such that when placed overan ostium of a bladder, the ostium is viewable through the hoop.
 2. Theablation instrument of claim 1, wherein said distal head and saidelongate shaft are sized and shaped for insertion into a urethra of ahuman patient.
 3. The ablation instrument of claim 1, further comprisinga scope slidably associated with said scope channel.
 4. The ablationinstrument of claim 1, wherein the elongate shaft defines a suctionchannel.
 5. The ablation instrument of claim 4, wherein the distal headcomprises a plurality of suction apertures arranged to hold tissue whensuction is applied.
 6. The ablation instrument of claim 5, wherein thedistal head further comprises a flat face and an angled face, each ofthe faces defining at least one of the plurality of suction apertures.7. The ablation instrument of claim 6, wherein the suction channel is influid communication with the plurality of suction apertures, and whereinthe ablation instrument further comprises a baffle member located in thesuction channel as a barrier between: (i) a portion of the suctionchannel adjacent the flat face and (ii) a portion of the suction channeladjacent the angled face.
 8. The ablation instrument of claim 4, whereinthe distal head comprises a suction face defining a plurality of suctionapertures, and wherein the scope channel extends at a non-zero angle αto the suction face.
 9. The ablation instrument of claim 8 wherein saidscope channel and said cannula channel are oriented such that said angleα results in an increased separation between a scope and the suctionface when the scope is advanced from a distal opening of the scopechannel.
 10. The ablation instrument of claim 8 wherein said angle α iswithin a range of 1-20 degrees.
 11. The ablation instrument of claim 8wherein said angle α is within a range of 5-15 degrees.
 12. The ablationinstrument of claim 8, wherein the plurality of suction apertures arearranged to hold tissue when suction is applied.
 13. The ablationinstrument of claim 12 wherein the distal head further comprises anangled face defining at least one suction aperture.
 14. The ablationinstrument of claim 1, further comprising a handle assembly attached tothe elongate shaft, and wherein the handle assembly includes a slidingmechanism shaped to receive and manipulate a scope.
 15. The ablationinstrument of claim 14, wherein the sliding mechanism includes a cutoutthat receives a feature on a scope such that rotation of the scoperelative to the instrument is prevented when the feature is in thecutout.
 16. The ablation instrument of claim 14, wherein the slidingmechanism defines a portion of the scope channel and is slidable tomanipulate a longitudinal position of a scope relative to the instrumentbetween: (i) a distal position in which a distal end of the scope isdistal of a distal end of the distal head and (ii) a retracted positionin which the distal end of the scope is within the scope channel. 17.The ablation instrument of claim 16, wherein the sliding mechanismincludes a stop member slidingly positioned within a groove defined bythe handle assembly, wherein the groove includes a proximal end and adistal end, wherein the distal position is established by the stopmechanism contacting the distal end of the groove, and wherein theretracted position is established by the stop mechanism contacting theproximal end of the groove.
 18. The ablation instrument of claim 14,wherein the sliding mechanism includes a stop member slidinglypositioned within a groove defined by the handle assembly.
 19. Theablation instrument of claim 1, wherein said positioning feature andsaid electrode are constructed and arranged such that when saidpositioning feature is aligned with a bladder ostium, the electrodeextended from the distal end of the associated cannula channel can entertissue proximal the ostium but not enter ostial tissue.